DISABILITY REPORT - ADULT - Form SSA-3368-BK

PLEASE READ ALL OF THIS INFORMATION BEFORE YOU BEGIN

COMPLETING THIS FORM

THIS IS NOT AN APPLICATION

IF YOU NEED HELP

If you need help with this form, do as much of it as you can, and your interviewer will help you
finish it. However, if you have access to the Internet, you may access the Disability Report
Form Guide at http://www.socialsecurity.gov/disability/3368/index.htm.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you
can.

Disability Report-Adult-Form SSA-3368-BK

• Please fill out as much of this form as you can before your interview appointment.
• Print or write clearly.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," please write: "don't know," or "none," or "does not apply."
• IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/
OTHER/HOSPITAL/CLINIC IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should include an area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
• If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
• If your appointment is for an interview in our office, bring the completed form with you or
mail it ahead of time, if you were told to do so.
• When a question refers to "you," "your" or the "Disabled Person," it refers to the person who
is applying for disability benefits. If you are filling out the form for someone else, please
provide information about him or her.
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
• If you need more space to answer any questions or want to tell us more about an answer,
please use the "REMARKS" section on Pages 9 and 10, and show the number of the
question being answered.

ABOUT YOUR MEDICAL RECORDS

If you have any medical records and copies of prescriptions at home for the person who is
applying for disability benefits, send them to our office with your completed forms or bring them
with you to your interview. Also, bring any medicine containers with you. If you need the
records back, tell us and we will photocopy them and return them to you.

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL

RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that
for you. The information we ask for on this form tells us to whom we should send a request for
medical and other records. If you cannot remember the names and addresses of any of the doctors
or hospitals, or the dates of treatment, perhaps you can get this information from the telephone
book, or from medical bills, prescriptions and medicine containers.
 WHAT WE MEAN BY "DISABILITY"
"Disability" under Social Security is based on your inability to work. For purposes of this claim,
we want you to understand that "disability" means that you are unable to work as defined by the
Social Security Act. You will be considered disabled if you are unable to do any kind of work for
which you are suited and if your disability is expected to last (or has lasted) for at least a year or to
result in death. So when we ask, "when did you become unable to work," we are asking when you
became disabled as defined by the Social Security Act.

The Privacy And Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on the named claimant's claim. While giving us the
information on this form is voluntary, failure to provide all or part of the requested information
could prevent an accurate or timely decision on the named claimant's claim. Although the
information you furnish is almost never used for any purpose other than making a determination
about the claimant's disability, such information may be disclosed by the Social Security
Administration as follows: (1) to enable a third party or agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal Laws
requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and the Department of Veterans Affairs); and (3) to facilitate statistical
research and such activities necessary to assure the integrity and improvement of the Social
Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social
Security).

We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits
paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given
out are available in Social Security offices. If you want to learn more about this, contact any
Social Security office.

PAPERWORK REDUCTION ACT: This information collection meets the requirements of

44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 60 minutes to read the instructions, gather the
facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security
Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.

PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

 Form Approved
SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0579

For SSA Use Only

Do not write in this box.
DISABILITY REPORT
Related SSN - -
ADULT
Number Holder

SECTION 1- INFORMATION ABOUT THE DISABLED PERSON

A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER

- -
C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you,
give us a daytime number where we can leave a message for you.)
( ) - Your Number Message Number None
Area Code Number

Disability Report-Adult-Form SSA-3368-BK

D. Give the name of a friend or relative that we can contact (other than your doctors) who
knows about your illnesses, injuries or conditions and can help you with your claim.
NAME
RELATIONSHIP

ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)

- DAYTIME ( ) -
City State ZIP
PHONE
Area Code Number

E. What is your F. What is your weight

height without without shoes?
shoes? feet inches pounds

G. Do you have a medical assistance card? (For Example, Medicaid YES NO

or Medi-Cal) If "YES," show the number here:

H. Can you speak and understand English? YES NO If "NO," what is your preferred
language?
NOTE: If you cannot speak and understand English, we will provide an interpreter, free of charge.
If you cannot speak and understand English, is there someone we may contact who speaks and
understands English and will give you messages? YES NO (If "YES," and that person is the
same as in "D" above show "SAME" here. If not, complete the following information.)
NAME RELATIONSHIP

ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)

- DAYTIME ( ) -
City State ZIP
PHONE Area Code Number

I. Can you read and YES NO J. Can you write more than YES NO
understand English? your name in English?

FORM SSA-3368-BK (3-2008) ef (03-2008) Use 6-2003 and Later editions Until Supply Is Exhausted PAGE 1
 SECTION 2
YOUR ILLNESSES, INJURIES OR CONDITIONS AND HOW THEY AFFECT YOU

A. What are the illnesses, injuries, or conditions that limit your ability to work?

B. How do your illnesses, injuries, or conditions limit your ability to work?

C. Do your illnesses, injuries or conditions cause you pain YES NO

or other symptoms?
D. When did your illnesses, injuries, or Month Day Year
conditions first interfere with your ability to
work?
E. When did you become unable to work because Month Day Year

of your illnesses, injuries, or conditions?

F. Have you ever worked? YES NO (If "NO," go to
Section 4.)
G. Did you work at any time after the date your
illnesses, injuries, or conditions first interfered with YES NO
your ability to work?
H. If "YES," did your illnesses, injuries, or conditions cause you to: (check all that apply)
work fewer hours? (Explain below)
change your job duties? (Explain below)
make any job-related changes such as your attendance, help needed, or employers?
(Explain below)

YES NO
I. Are you working now?
Month Day Year
If "NO," when was the last day you worked?

J. Why did you stop working?

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 2

 SECTION 3 - INFORMATION ABOUT YOUR WORK
A. List all the jobs that you had in the 15 years before you became unable to work
because of your illnesses, injuries or conditions.
TYPE OF DATES WORKED RATE OF PAY
(month & year) HOURS DAYS
JOB TITLE BUSINESS PER PER (Per hour, day,
(Example, Cook) (Example, DAY WEEK week,
Restaurant) FROM TO month or year)

B. Which job did you do the longest?

C. Describe this job. What did you do all day? (If you need more space, write in the
"Remarks" section.)

D. In this job, did you:

Use machines, tools or equipment? YES NO
Use technical knowledge or skills? YES NO
Do any writing, complete reports, or perform duties like this? YES NO

E. In this job, how many total hours each day did you:
Walk? Stoop? (Bend down & forward at waist.) Handle, grab, or grasp big objects?
Stand? Kneel? (Bend legs to rest on knees.) Reach?
Sit? Crouch? (Bend legs & back down & forward.) Write, type, or handle small objects?
Climb? Crawl? (Move on hands & knees.)
F. Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

G. Check heaviest weight lifted:

Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other

H. Check weight frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other

I. Did you supervise other people in this job? YES (Complete items below.) NO (If NO, go to J.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees? YES NO
J. Were you a lead worker? YES NO
FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 3
 SECTION 4 - INFORMATION ABOUT YOUR MEDICAL RECORDS
A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses,
injuries or conditions that limit your ability to work? YES NO

B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or

mental problems that limit your ability to work? YES NO

If you answered "NO" to both of these questions, go to Section 5.

C. List other names you have used on your medical records.

Tell us who may have medical records or other

information about your illnesses, injuries or conditions.

D. List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment.

1 NAME
DATES
STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST VISIT

-
PHONE ( ) - PATIENT ID # (If known) NEXT APPOINTMENT
Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

2 NAME
DATES
STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST VISIT

-
PHONE ( ) - PATIENT ID # (If known) NEXT APPOINTMENT
Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 4

 SECTION 4 - INFORMATION ABOUT YOUR MEDICAL RECORDS

DOCTOR/HMO/THERAPIST/OTHER
3. NAME DATES
STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST VISIT

-
PHONE ( ) - PATIENT ID # (If known) NEXT APPOINTMENT
Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

If you need more space, use Section 9 - Remarks.

E. List each HOSPITAL/CLINIC. Include your next appointment.

1. HOSPITAL/CLINIC TYPE OF VISIT DATES

NAME INPATIENT DATE IN DATE OUT
STAYS
(Stayed at least
STREET ADDRESS overnight)
DATE FIRST VISIT DATE LAST VISIT
OUTPATIENT
VISITS
CITY STATE ZIP (Sent home same
day)
- DATES OF VISITS
PHONE
( ) - EMERGENCY
ROOM VISITS
Area Code Phone Number

Next appointment Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 5

 SECTION 4-INFORMATION ABOUT YOUR MEDICAL RECORDS

HOSPITAL/CLINIC
2. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT DATE IN DATE OUT
STAYS
(Stayed at least
STREET ADDRESS overnight)
DATE FIRST VISIT DATE LAST VISIT
OUTPATIENT
VISITS
CITY STATE ZIP (Sent home same
day)
- DATES OF VISITS
PHONE
( ) - EMERGENCY
ROOM VISITS
Area Code Phone Number

Next appointment Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

If you need more space, use Section 9 - Remarks.

F. Does anyone else have medical records or information about your illnesses, injuries,
or conditions (Workers' Compensation, insurance companies, prisons, attorneys,
welfare), or are you scheduled to see anyone else?

YES (If "YES," complete information below.) NO

NAME DATES
STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST VISIT

-
PHONE ( ) - NEXT APPOINTMENT
Area Code Phone Number

CLAIM NUMBER (if any)

REASONS FOR VISITS

If you need more space, use Section 9 - REMARKS.

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 6
 SECTION 5 - MEDICATIONS
Do you currently take any medications for your illnesses, injuries or conditions? YES
If "YES," please tell us the following: (Look at your medicine containers, if necessary.) NO

IF PRESCRIBED, GIVE REASON FOR SIDE EFFECTS

NAME OF MEDICINE
NAME OF DOCTOR MEDICINE YOU HAVE

If you need more space, use Section 9 - Remarks.

SECTION 6 - TESTS

Have you had, or will you have, any medical tests for illnesses, injuries, or conditions?
YES NO If "YES," please tell us the following: (Give approximate dates, if necessary.)

WHEN WAS/
WILL TESTS WHERE DONE? WHO SENT YOU FOR
KIND OF TEST
BE DONE? (Name of Facility) THIS TEST?
(Month, day, year)
EKG (HEART TEST)

TREADMILL (EXERCISE TEST)

CARDIAC CATHETERIZATION

BIOPSY -- Name of body part

HEARING TEST

SPEECH/LANGUAGE TEST

VISION TEST

IQ TESTING

EEG (BRAIN WAVE TEST)

HIV TEST

BLOOD TEST (NOT HIV)

BREATHING TEST

X-RAY -- Name of body part

MRI/CT SCAN -- Name of body

part

If you have had other tests, list them in Section 9 - Remarks.

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 7
 SECTION 7-EDUCATION/TRAINING INFORMATION
A. Check the highest grade of school completed.
Grade school: College:
0 1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4 or more

Approximate date completed:

B. Did you attend special education classes? YES NO (If "NO," go to part C)
NAME OF SCHOOL

ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box or Rural Route)

-
City State ZIP

DATES ATTENDED TO

TYPE OF PROGRAM
C. Have you completed any type of special job training, trade or vocational school?
YES NO If "YES," what type?

Approximate date completed:

SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT,
or OTHER SUPPORT SERVICES INFORMATION
Have you participated, or are you participating in:
• an individual work plan with an employment network under the Ticket to Work Program;
• an individualized plan for employment with a vocational rehabilitation agency or any other organization;
• a Plan to Achieve Self-Support;
• an individualized education program through an educational institution (if a student age 18-21); or
• any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
YES (Complete the information below) NO
NAME OF ORGANIZATION OR SCHOOL

NAME OF COUNSELOR OR INSTRUCTOR

ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box or Rural Route)

-
City State ZIP

DAYTIME PHONE NUMBER ( ) -

Area Code Number

DATES SEEN TO
TYPE OF SERVICES,
TESTS OR EVALUATIONS
PERFORMED (IQ, vision, physicals, hearing, workshops, classes, etc.)
FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 8
 SECTION 9 - REMARKS
Use this section for any additional information you did not show in earlier parts of this
form. When you are finished with this section (or if you don't have anything to add),
be sure to go to the next page and complete the blocks there.

FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 9

 SECTION 9 - REMARKS

Name of person completing this form if other than the disabled Date Form Completed (Month, day, year)
person (Please print)

E-Mail Address of person completing this form (optional)

If the person completing this form is other than the disabled person or the person identified in Section 1. Item D.,
please complete the following information.
Relationship to Disabled Person Daytime Telephone Number
( ) -
Address (Number and street) City State ZIP
-
FORM SSA-3368-BK (3-2008) ef (03-2008) PAGE 10